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A Medical H&P - Example 2 — Transcript

by Strong Medicine · 2,124 words · 332 segments · language en · Watch on YouTube

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0:01hello it's Eric from strong medicine
0:03this is another demonstration of an oral
0:06presentation of a medical h&p as with
0:09the previous one I'll be giving two
0:11demonstrations of the same case the
0:13first will be a relatively detailed
0:16so-called complete hmp that I would
0:19expect of a clerkship student on a
0:20service that was not unusually busy the
0:24second will be a much more concise
0:26version that I'd expect from a seasoned
0:28resident or from an intern or suby who
0:31was on an unusually busy team for which
0:34the presentation of a complete hmp was
0:37just not
0:44practical the primary source of
0:46information is the patient who appears
0:47reliable though the interview was
0:50deliberately kept brief due to her acute
0:52illness the chief complaint Miss White
0:55is a 38-year-old woman with no relevant
0:57past medical or social history who
1:00presented with dpia for several hours uh
1:03Miss White uh reported being in her
1:04usual state of health until 5 days ago
1:07at which time she was struck by a
1:08bicyclist while at work at a high school
1:11resulting in a scrape to her right
1:13lateral calf against a parking lot
1:16pavement it was cleaned and dressed at
1:19the time by the school nurse uh and then
1:223 days ago she had the onset of
1:24worsening pain and swelling in the right
1:26leg she saw an outpatient physician who
1:28diagnosed her with cellulitis
1:30and started sexin despite taking the
1:33antibiotic as prescribed one day ago she
1:35developed a subjective fever and chills
1:38and was generally just kind of feeling
1:40poorly then last night or maybe in the
1:43early hours of the morning her husband
1:46thought she appeared to be unwell so he
1:48woke her in order to check up on how she
1:50was doing at that point the patient
1:52reported she felt her breathing was
1:54difficult she was diaphoretic and had a
1:57measured temperature of 102 so so that
2:00prompted her to come to the ER she
2:03reported no pain in her left leg her
2:05abdomen chest or neck she reported no
2:08nausea vomiting changes in B habits or
2:11Li headedness her past medical history
2:14is only notable for childhood asthma
2:16which has been asymptomatic for many
2:18years surgical OBG and psychiatric
2:22histories were not explicitly discussed
2:25her only medication has been the
2:26aformentioned sexin four times a day she
2:30takes no over-the-counter meds or
2:33supplements um regarding her social
2:35history uh she lives in a condo in
2:38Cupertino with her husband uh and their
2:40four-year-old daughter both of their
2:42health is fine she works as a high
2:45school physics and chemistry teacher uh
2:47but she reports no recent chemical
2:49exposures at work uh from any kind of
2:51experiment or demonstration uh she has
2:54no pets at home or other animal
2:55exposures her only recent travel was to
2:58Los Angeles 2 months ago
3:00she drinks a couple of beers or glasses
3:02of wine on the weekend she is a
3:04non-smoker and she reports no history of
3:07Recreation on drug use family history
3:10and additional review of systems were
3:12not covered on physical exam obtained
3:16after 2 lers of IV fluids in the ER Miss
3:19White appeared fatigued and a bit unwell
3:22her temperature was 38.5 her pulse was
3:25118 blood pressure 85 over 62 resp we 26
3:30and O2 sat 92% on 4 liters via nasal
3:33canula she had moderate crackles
3:35throughout both lungs on cardiovascular
3:38exam she had a regular teoc cardia with
3:40normal S1 and S2 with no murmur or
3:42gallops her jvp was not visible with her
3:45at 30 degrees her radial DP and PT
3:48pulses were all diminished bilaterally
3:50Pocus revealed a collapsing non-dilated
3:53IBC and Hyper dnamic LV function abdomen
3:56was soft and non- tender her right leg
3:59had anra to the lateral calf that
4:02appeared clean and was out and was
4:04without necrotic tissue or drainage the
4:06right leg was diffusely warm and tender
4:08with pitting edema extending to just
4:09above the right knee but neither
4:12crepitus nor tenderness extending beyond
4:14the edema was present there was no pain
4:17on passive range of motion testing at
4:19either the right knee or the right ankle
4:22she has no palpable lymph nodes in the
4:23head neck axillary or ininal regions her
4:26no exam was unremarkable though gate was
4:28deferred due to to her hypotension and
4:31acute illness uh moving to tests her
4:34white blood cell count was 14,000 with h
4:37glin of 12 uh and platelets of
4:40135 chemistry panel was most notable for
4:44a bu of 22 C of 1.9 and an anine gap of
4:4819 her lactate was 4.2 uh and troponin
4:51was normal Hest x-ray was a reasonable
4:54quality portable film with moderate
4:56diffuse bilateral pulmonary edema she
4:59know if fusions and she had a normal
5:01cardiac silhouette ECG showed sinus of
5:04cardia at 118 beats per minute uh with a
5:07normal axis normal intervals and no stt
5:11changes in summary Miss White is a
5:1338-year old woman with no notable past
5:15history who presented with acute dnia
5:18and fever in the setting of a recent
5:19diagnosis of right- leg cellulitis
5:22secondary to trauma the exam was most
5:24notable for fever blood pressure of 85
5:26over 62 despite 2 lers of fluid an O2
5:30set of 92% on 4 lers bilateral crackles
5:34right- leg cellulitis without signs of
5:36necrotizing fasciitis or compartment
5:38syndrome intact mental status and Pocus
5:41with a with a non-dilated and collapsing
5:44IBC and Hyper dnamic
5:47LV other data includes
5:54lucyisanerd shock
5:59secondary to cellulitis this white has
6:02sepsis as demonstrated by the classic
6:04Vital sign abnormalities and an overt
6:06source of infection classifying it as
6:09septic shock albeit relatively mild is
6:12based on the persistance of hypotension
6:14despite IV fluids and her elevated
6:17lactate the most likely scenario is that
6:19her solitis was secondary to a
6:21particularly virulent organism and or
6:23One resistant to sexin such as MRSA
6:27which then led to
6:28bacteremia one consideration is whether
6:30she has necrotizing fasciitis or other
6:32necrotizing soft tissue infection
6:34although she does have serious systemic
6:36illness the lack of crepitus or pain out
6:39of proportion to the exam argues a
6:41little against this uh her uh linic
6:44score a clinical prediction rule for
6:45necrotizing fasciitis can't can't be
6:48calculated yet without a CRP level but
6:50the remainder of the scores factors are
6:52consistent with relatively low risk
6:55though this score has a suboptimal
6:57negative predictive value the diagnostic
7:00plan for her shock and cellulitis
7:02includes following up blood and urine
7:04cultures which are already
7:06drawn given the lack of known
7:09subcutaneous fluid collections necrotic
7:12tissue or soft tissue crepitus there is
7:14no obvious specific indication for
7:16Source control via percutaneous or
7:18surgical intervention and likewise a
7:21wound culture at this time will likely
7:23not be diagnostically helpful however
7:26given the low but non-trivial
7:27possibility of necrotizing f aitis which
7:30is an acutely life-threatening diagnosis
7:33we will still consult general surgery
7:36and obtain a CT scan of the right leg
7:39we've also ordered a CRP to formally
7:41calculate the lenic score and a CK CK
7:45level to evaluate the possibility of
7:48pyomyositis therapeutically I would
7:50normally aggressively push more fluids
7:52using mean arterial pressure decreasing
7:55lactate and urine output as surrogates
7:57for adequate adequate itation however in
8:01this case I'm I'm hesitant to do uh to
8:03do this to be more aggressive given her
8:05pulmonary edema so instead we'll plan to
8:08bolish another 500 cc's of LR now and if
8:11that's insufficient we'll start Norine
8:13nephrine for antibiotic coverage I'll
8:16treat broadly for now with bomy and
8:18sapim while blood cultures are pending
8:21and will narrow as able for pain control
8:24we will use standing Tylenol and PRN
8:26oxycodone and IV morphine
8:29problem number two is her hypoxemia uh
8:32given the combination of her chest x-ray
8:34with hypodynamic LV function and
8:36evidence of low CVP this is most likely
8:40non-cardiogenic pulmonary edema
8:42secondary dypsis and represents neither
8:44pneumonia nor concurrent heart failure
8:47we will continue supplemental oxygen is
8:49necessary positive pressure ventilation
8:52is not currently
8:53indicated problem number three is
8:56presumed Aki presumed because we don't
8:59actually have a baseline katne for
9:01comparison however in a previously
9:03healthy 38-year-old it's highly likely
9:06to have been normal the Aki is either
9:09from Pure dehydration or from ATN
9:12secondary topsis will send off a UA and
9:15Fina to help distinguish between these
9:16two
9:17possibilities though doing so won't
9:19necessarily change acute management it
9:21will provide a very general idea of the
9:24expected timing of renal
9:26recovery lastly code status and goals of
9:29care were not discussed with her but we
9:32will do so at the next opportunity until
9:35then she will be full code given the
9:37severity of her illness speculation
9:39regarding her anticipated discharge plan
9:41would be
9:51premature Miss White is a 38-year-old
9:54woman with no relevant past medical or
9:55social history who presented with dnia
9:58for several hours
9:59she reported being in her usual state of
10:01health until 5 days ago at which time
10:03she was struck by a bicyclist that while
10:05work resulting in a scrape to a right
10:07lateral calf against a parking lot
10:09pavement it was cleaned and dressed at
10:12the time 3 days ago she had the onset of
10:14worsening pain and swelling in the right
10:16leg an outpatient clinician diagnosed
10:18her with cellulitis and prescribed
10:21sexin despite the antibiotic she went on
10:23to develop subjective fevers and chills
10:26then in the early hours of this morning
10:28she noted dnia diaphoresis and had a
10:32temperature measured at 102 prompting
10:34her to come to the ER she reported no
10:37pain other than in her right leg also
10:39know nausea vomiting changes in Bow
10:41habits neck stiffness or
10:44lightheadedness her only medication has
10:46been the aformentioned
10:47sexin regarding her social history she
10:50lives in a condo in Cupertino with her
10:52husband and four-year-old daughter both
10:55of their health is fine she reports no
10:58occupational animal or travel related
11:01exposures she reports modest alcohol
11:03intake but no smoking or recreational
11:05drug use on exam obtained after 2 lers
11:09of fluids M white appeared fatigued and
11:12unwell her temp was 38.5 pulse 118 blood
11:16pressure 85 over 62 respiratory rate 26
11:20and O2 sat was 92% on 4 lers she had
11:24moderate bilateral crackles but no
11:26murmurs or gallops Pocus revealed a
11:28collapse ing non-dilated IBC and a
11:31hypodynamic LV abdomen was soft and non-
11:34tender her right leg had an abration to
11:36the lateral calf that appeared clean and
11:38was without necrotic tissue or drainage
11:41the right leg was diffusely warm and
11:42tender with pitting edema extending to
11:44just above the right knee but neither
11:46crepitus nor tenderness extending beyond
11:49the edema was present there was no pain
11:51on passive range of motion testing of
11:53the right knee or ankle she has no
11:55palpable nodes her neur exam was
11:57unremarkable though gate was deferred on
12:01tests her white blood cell count was 14
12:04with a hemoglobin of 12 chemistry is
12:06most notable for a cranon of 1.9 and a
12:08lactate of 4.2 a chest x-ray showed
12:12moderate diffuse pulmonary edema ECG
12:14showed sinus attack and was otherwise
12:17normal so in summary Miss White is a
12:2038-year-old previously healthy woman now
12:22with acute dnia and fever in the setting
12:25of a recent diagnosis of right leg
12:27cellulitis secondary trauma the exam is
12:30most notable for fever hypotension
12:33despite 2 lers of fluid an O2 sat of 92%
12:36on four lers red leg cellulitis without
12:39signs of necrotizing fasciitis or
12:41compartment syndrome and Pocus with a
12:44non-dilated and collapsing IBC and hyp
12:47dnamic
12:48LV other data includes
12:58lucyisanerd problem number one septic
13:00shock secondary to cellulitis an
13:02important consideration is whether she
13:04also has necrotizing
13:06fasciitis though she has serious
13:08systemic illness the lack of crepitus or
13:11pain out of proportion to the exam
13:13argues a little against this her lenic
13:16score can't be calculated yet without a
13:18CRP level but the remainder of the
13:20scores factors are consistent with
13:22relatively low risk however given the
13:25low but non-trivial possibility of neck
13:28fash we will still consult general
13:30surgery and obtain a CT of the right leg
13:33CRP and CK are also pending
13:36therapeutically we'll plan to bolus
13:38another 500 cc's of LR and if that's
13:41insufficient we'll start norepinephrine
13:44for antibiotic coverage Vin seapine for
13:46now for pain control we will use
13:48standing Tylenol and PRN oxy and IV
13:52morphine problem two is our hypoxemia
13:55secondary dypsis triggered
13:57non-cardiogenic pulmonary edem
13:59will continue supplemental O2 as
14:02necessary problem number three is a
14:04presumed Aki secondary to either pure
14:07dehydration or from ATN will send off a
14:10UA and Fina to help distinguish between
14:12these two lastly code status and goals
14:14of care were not discussed with her but
14:17we will do so at the next opportunity

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